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�- APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES? ENVIRONMENTAL HEALTH DIVISION �j 445 N SAN JOAQUIN, PHONE (209)468-3420 0 .� P O BOX 2009, STOCKTON, CA 95201 Q � PERMIT EXPIRES I YEAR FROM DATE ISSUED � 4` (Complete in Triplicate) Application is hereby Stade to Ban Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.. 549 and 1862 and the Rules and Regulations of Bart Joaquin County Public Health Services. Job Address �� • �1 s�C? - City Lot Size/Acreage owner's Name b Address 2.1 t W•tAtA l"-4t:ZyZ`f �!^� Phone 4q1 1-44 Contractor. 12 Address License No, Phone TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ` l'] Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern _ Surface Seal Installed by Repair Work Done U Type of Pump H,P. State Work Done _ WeH Destruction ❑ Well Diameter' Sealing Material i Depth Depth Piller Material i Depth PE OF SEPTIC WORK: NEW INSTALLATION E I REPAIR/ADDITION I 1 DESTRUCTION 1No Septic system permined if pts war is vailable within 200 feet.) Installation ' serve: Residence_ Commercial_ Other Number of living u Number of bedrooms QS Character of MO.to a dept fest: Water table depth SEPTIC TANK 0 Typs/ Capacity No. Compartments PKG. TREATMENT PLT. Q Method of Disposal Distance to nearest: We undstion Property Line LEACHING LINE ❑ No. 8 Length of lines �Iengtth/sizeFILTER BED Cl Distance to nes Well Foundation 5 SEEPAGE PITS l i th Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSA S ❑ certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's!tiring or sub-contracting signature eanifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant call r all requi inspections. Complete drawing on reverse side. igned Title: � ✓� � Date: r2r 2 F R DEPARTMENT USE ONLY Application Accepted by A c, L — Date Z^ z Ar f n 11— Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INF AMOUNT DUE AMOUyr REMtTTED K R CEiVED BY O T PERMIT-NO. . EH 15.761111EV.�in61 ! EH 473